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To ensure that all matters dealing with the accreditation of programs by the Accreditation Commission for Education in Nursing (ACEN) are conducted with integrity, fairness, impartiality, and objectivity, the ACEN has adopted this transition-to-practice policy addressing conflict of interest, conduct, and confidentiality.

CONFLICT OF INTEREST FOR PEER EVALUATORS

In all circumstances, not only conflicts of interest, but also the appearance of conflicts of interest, must be avoided. All peer evaluators, Commissioners, Appeal Panel members, and any other individuals who act on behalf of the ACEN shall not have direct involvement with and/or participate in any decision-making capacity for a transition-to-practice program if they have an actual or potential conflict of interest with the transition-to-practice program. Actual or potential conflicts of interest may include, but are not limited to, the following:

1. Maintaining employment with or serving as a graduate advisee/advisor involving the sponsoring organization that is under review;

2. Being a current student, former student, or graduate of the sponsoring organization that is under review;

3. Being a current employee or former employee of the sponsoring organization that is under review;

4. Maintaining employment in the same state as the transition-to-practice program that is under review;

5. Having served as a peer evaluator in the past three years on any ACEN accreditation matter involving the transition-to-practice program or sponsoring organization that is under review;

6. Having served as a consultant in the past three years on any accreditation matters involving the transition-to-practice program or sponsoring organization that is under review;

7. Having jointly authored research or literature, participated in a common consortium, or been involved in special research with current program educators of the transition-to-practice program that is under review;

8. Having served in an evaluation role in the past three years for an agency other than the ACEN regarding the same transition-to-practice program or sponsoring organization that is under review, including but not limited to membership on the board for the state regulatory agency, regional accreditation teams, or evaluation committees for boards of trustees or regents;

9. Having been paid or otherwise profited or appeared to profit from service in the past three years to the transition-to-practice program or sponsoring organization that is under review;

10. Having affiliations or close personal or professional relationships in the past three years with key personnel in the transition-to-practice program or sponsoring organization that is under review;

11. Having immediate family members who are current employees, board members, or nurse residents at the sponsoring organization that is under review;

12. Having a current financial interest in the sponsoring organization that is under review, including but not limited to ownership of shares of stock in the sponsoring organization or any parent of the sponsoring organization, excepting shares or interests held indirectly, such as in mutual funds, insurance policies, or blind trusts. In addition, having any immediate family members with any of the above financial interests; and

13. Having any other relationship or reason that could serve as an impediment to rendering an impartial, objective professional judgment regarding the transition-to-practice program that is under review.

CONDUCT AND ETHICAL GUIDELINES FOR TRANSITION-TO-PRACTICE PROGRAMS AND PEER EVALUATORS

Responsibilities of Transition-to-Practice Programs Seeking Accreditation

1. It is the responsibility of each transition-to-practice program to facilitate a thorough and objective appraisal of its transition-to-practice program.

2. Transition-to-practice programs may veto a peer evaluator if it can be demonstrated, in writing to the ACEN Chief Executive Officer, that an actual or a potential conflict of interest exists.

3. Any perceived inadequacies of the ACEN procedures or processes should be reported by the nurse administrator of the transition-to-practice program to the ACEN Chief Executive Officer at the time of the occurrence rather than withheld until after the ACEN Board of Commissioners makes an accreditation decision.

Responsibilities of Peer Evaluators

1. Any Commissioner who was a member of a site visit team for a transition-to-practice program under consideration or resides in or is currently employed in the same state as the transition-to-practice program under consideration must recuse her/himself from the discussion about the transition-to-practice program and abstain from voting.

2. Any Commissioner who is employed by a sponsoring organization of a transition-to-practice program being considered for accreditation must recuse her/himself from the portion of the Commission meeting agenda concerned with the evaluation of that transition-to-practice program and abstain from voting.

3. Peer evaluators will be reminded of the confidentiality of all information pertaining to the review of transition-to-practice programs and the need to avoid any actions that might give the appearance of a conflict of interest or could reasonably be perceived as affecting their objectivity. Peer evaluators are required to refrain from accepting membership on a team, recuse themselves from the discussion during the review of any transition-to-practice program if their presence would constitute or appear to constitute a conflict of interest, and abstain from voting if a conflict of interest is identified.

Actions to be Avoided by Peer Evaluators

1. Advertising of one’s status as an ACEN peer evaluator for the purpose of consulting;

2. Soliciting consultation arrangements with transition-to-practice programs preparing for accreditation review;

3. Giving advice to a transition-to-practice program or consulting for a transition-to-practice program for a period of two years after serving as a peer evaluator on any ACEN transition-to-practice program accreditation matter; and

4. Offering definitive answers related to any ACEN policies and procedures or Transition-to-Practice Standards and Criteria.

CONFLICT OF INTEREST, CONDUCT, AND ETHICAL GUIDELINES FOR ACEN STAFF

In all circumstances, not only conflicts of interest, but also the appearance of conflicts of interest, must be avoided. No staff member shall have direct involvement with a transition-to-practice program if they have an actual or potential conflict of interest with the transition-to-practice program.

Staff members should inform the ACEN Chief Executive Officer where an actual or potential conflict of interest exists. A conflict of interest exists if a staff member:

1. Was a compensated consultant, appointee, employee of, or candidate for employment at the transition-to-practice program or sponsoring organization within the past three years;

2. Has a close personal or familial relationship with persons at the sponsoring organization;

3. Has a strong bias regarding the transition-to-practice program or sponsoring organization;

4. Has any other relationship or reason that could serve as an impediment to acting in an impartial, objective professional manner toward the transition-to-practice program or sponsoring organization; or

5. Has a current financial interest in the sponsoring organization under review, including but not limited to ownership of shares of stock in the sponsoring organization or any parent of the sponsoring organization, excepting shares or interests held indirectly, such as but not limited to in mutual funds, insurance policies, or blind trusts, or has any immediate family members with any of the aforementioned financial interests.

In addition, staff members are prohibited from accepting fees, awards, or honorary degrees from a sponsoring organization with a transition-to-practice program that is accredited by the ACEN.

CONFIDENTIALITY AND COMMUNICATIONS FOR PEER EVALUATORS AND ACEN STAFF

To ensure that all matters dealing with the accreditation of transition-to-practice programs are conducted with integrity, fairness, impartiality, and objectivity, the ACEN has adopted this confidentiality policy. Individuals who participate in ACEN activities, including but not limited to peer evaluators and ACEN staff members, must maintain confidentiality with regards to all non-public information related to the accreditation review and consideration of a transition-to-practice program by the ACEN. Accordingly, peer evaluators and ACEN staff members shall conduct themselves as follows:

1. Documents, reports, and other materials prepared by the transition-to-practice program for the ACEN must be treated as confidential materials in the absence of specific policies that make clear the degree and extent of their exposure. The ACEN will release materials in response to a valid court order or otherwise as may be required by law.

2. All materials pertinent to the transition-to-practice program under review are considered confidential materials prepared for use by the ACEN and should not be shown to or discussed with anyone other than peer evaluators and ACEN staff members as appropriate and when necessary.

3. The accreditation decision issued by the ACEN Board of Commissioners will be communicated to the transition-to-practice program leaders in writing by the ACEN Chief Executive Officer.

4. A peer evaluator or ACEN staff member shall not share with a sponsoring organization/transition-to-practice program employee or any other person information about the review proceedings.

5. Any request by a peer evaluator for additional information from the sponsoring organization/transition-to-practice program following a site visit must be directed to the ACEN professional staff. There will be no direct communication between a peer evaluator and the sponsoring organization and/or transition-to-practice program under review except in preparation for an upcoming site visit.

Policy 201 History

Initial Approval: July 24, 2019

Site visit teams for transition-to-practice programs are composed of peer evaluators. Peer evaluators are defined by the ACEN as program educators from transition-to-practice programs, nurse educators from colleges/universities, and nurse clinicians/practitioners. The ACEN Board of Commissioners is composed of nurse educators from colleges/universities, nursing clinicians/practitioners, and members of the public.

PROGRAM EDUCATORS FROM TRANSITION-TO-PRACTICE PROGRAMS

Program educators work in transition-to-practice programs. They are responsible for educating nurse residents at all levels of nursing practice. Program educators are responsible for designing, implementing, evaluating, and revising transition-to-practice programs.

Program educators are individuals who:

1. Currently hold a position in a transition-to-practice program.

2. Held a position in a transition-to-practice program and is retired for no more than two years from this position.

And who have:

    • Knowledge of contemporary healthcare settings, transitions in nursing practice, and current issues and trends in nursing practice.
    • Expertise in communication, group dynamics, information literacy, use of technology, and best practices in clinical settings.
    • Made contributions in practice, community service, and professional service.

Program educators are eligible to serve on a transition-to-practice site visit team as a team member or team chair. Program educators are eligible to serve on the ACEN Board of Commissioners if qualified to serve as a nurse clinician/practitioner per the ACEN requirements specified for nursing education programs.

NURSE EDUCATORS FROM COLLEGES AND UNIVERSITIES

Nurse educators from colleges and universities teach nursing students in the classroom, laboratory, and/or practice settings. Nurse educators are responsible for designing, implementing, evaluating, and revising nursing education programs that lead to a certificate, diploma, associate degree, baccalaureate degree, master’s degree, post-master’s certificate, clinical doctorate, and/or DNP specialist certificate.

Nurse educators are individuals who:

1. Currently hold a position in an ACEN-accredited preparatory nursing education program.

2. Held a position in an ACEN-accredited preparatory nursing education program and have been retired for no more than two years from this position.

And who have:

    • Knowledge of contemporary healthcare settings, transitions in nursing practice, and current issues and trends in nursing practice. Expertise in communication, group dynamics, information literacy, use of technology, best practices for patient health and safety, best educational practices, teaching, and learning.
    • Made contributions in scholarship/research, practice, community service, professional service.

Nurse educators are eligible to serve on any type of site visit team as a team member or team chair, and the ACEN Board of Commissioners.

NURSE CLINICIANS/PRACTITIONERS

Nurse clinicians/practitioners are licensed nurses who are responsible and accountable for organizing, planning, assigning, and overseeing nursing care of individuals, families, groups, and communities who:

1. Currently hold a nursing position in a clinical practice environment.

2. Held a nursing position in a clinical practice environment and have been retired for no more than two years from this position.

And who have:

    • Knowledge of contemporary healthcare settings, transitions in nursing practice, and current issues and trends in nursing practice.
    • Expertise in communication, group dynamics, information literacy, use of technology, best practices for patient health and safety.
    • Made contributions in scholarship/research, practice, community service, professional service.

Nurse clinicians/practitioners are eligible to serve on a transition-to-practice site visit team as a team member or team chair. Nurse clinicians/practitioners are eligible to serve on the ACEN Board of Commissioners if qualified to serve as a nurse clinician/practitioner per the ACEN requirements specified for nursing education programs.

PUBLIC MEMBERS

Public members are individuals with no connection to the discipline of nursing. An individual representing the public may not be:

1. An employee, owner, or shareholder of a sponsoring organization with any accredited or non-accredited transition-to-practice program or candidate/applicant transition-to-practice program;

2. A member of the governing board for a sponsoring organization with any accredited or non-accredited transition-to-practice program or candidate/applicant transition-to-practice program;

3. A consultant to any accredited or non-accredited transition-to-practice program or candidate/applicant transition-to-practice program;

4. Affiliated or associated with any nursing accreditation agency or nursing organization, such as but not limited to the American Association of Colleges of Nursing (AACN), American Nurses Association (ANA), or National League for Nursing (NLN); or

5. A spouse, parent, child, or sibling of an individual identified in the above statements.

Public members are eligible to serve on the ACEN Board of Commissioners.

The ACEN Chief Executive Officer reserves the right to appoint one or more special members who may not be a program educator from a transition-to-practice program, nurse educator from a college/university, or clinician to a transition-to-practice site visit team. The special member or members may have expertise in an area that a program educator, nurse educator, and/or clinician typically would not have. The sponsoring organization/transition-to-practice program is responsible for all costs of the special members serving on the site visit team.

The ACEN Chief Executive Officer reserves the right to:

(a) Have an ACEN staff member accompany a site visit team. If an ACEN staff member accompanies a site visit team, the staff member would offer guidance to the peer evaluators. The sponsoring organization/transition-to-practice program is responsible for all costs of the professional staff member accompanying the site visit team.

(b) Have an ACEN staff member serve on a site visit team. If an ACEN staff member serves on a site visit team, the staff member would serve as a peer evaluator. The sponsoring organization is responsible for all costs of the staff member serving on the site visit team.

Policy 202 History

Initial Approval: July 24, 2019

To be eligible for initial or continuing accreditation, the sponsoring organization and transition-to-practice program must demonstrate that they meet or continue to meet all the eligibility and continuing eligibility requirements of the ACEN.

SPONSORING ORGANIZATION ELIGIBILITY

A. Eligibility requirements for the sponsoring organization offering the transition-to-practice program seeking initial accreditation with the ACEN

1. For transition-to-practice programs administered by a college, university, or technical/vocational sponsoring organizations, the sponsoring organization must:

    • be accredited with an institutional accrediting agency recognized by the ACEN before the ACEN Board of Commissioners makes its initial accreditation decision for the transition-to-practice program(s) seeking initial accreditation with the ACEN; and
    • be legally authorized by an appropriate state agency, as applicable, to offer credit or non-credit programs before the ACEN Board of Commissioners makes its initial accreditation decision for the transition-to-practice program(s) seeking initial accreditation with the ACEN.

2. For transition-to-practice programs administered by a healthcare services organization, the sponsoring organization must:

    • be accredited or recognized by an agency recognized by the ACEN before the ACEN Board of Commissioners makes its initial accreditation decision for the transition-to-practice program(s) seeking initial accreditation with the ACEN; and
    • be legally authorized by an appropriate state agency, as applicable, to offer healthcare services.

3. The nurse administrator of the transition-to-practice program is responsible for immediately informing the ACEN Chief Executive Officer, in writing, of any change of status with any agency that accredits and/or approves the sponsoring organization. The notification must occur before the ACEN Board of Commissioners makes its initial accreditation decision.

B. Continuing Eligibility requirements for the sponsoring organization offering the transition-to-practice program seeking continuing accreditation with the ACEN

1. For transition-to-practice programs administered by a college, university, or technical/vocational sponsoring organizations, the sponsoring organization must:

    • be accredited with an institutional accrediting agency recognized by the ACEN before the ACEN Board of Commissioners makes its accreditation decision; and
    • be legally authorized by an appropriate state agency, as applicable, to offer credit or non-credit programs.

2. For transition-to-practice programs administered by a healthcare services organization, the sponsoring organization must:

    • be accredited or recognized by an agency recognized by the ACEN; and
    • be legally authorized by an appropriate state agency, as applicable, to offer healthcare services.

3. The nurse administrator of the transition-to-practice program is responsible for immediately informing the ACEN Chief Executive Officer, in writing, of any change of status with any agency that accredits and/or authorizes the sponsoring organization. The notification must occur before the ACEN Board of Commissioners makes its continuing accreditation decision.

Policy 203 History

Initial Approval: July 24, 2019

A transition-to-practice program is considered for initial or continuing accreditation by the ACEN Board of Commissioners when it demonstrates compliance with the Transition-to-Practice Standards and Criteria.

INITIAL ACCREDITATION

Granted

Initial accreditation of a transition-to-practice program is granted when the transition-to-practice program demonstrates compliance with all Accreditation Standards. Next review shall be in four years.

Granted With Contingency

Initial accreditation with contingency of a transition-to-practice program is granted when the ACEN Board of Commissioners finds a transition-to-practice program demonstrates compliance with all but one Accreditation Standard. Next review shall be a review of written documentation regarding the Accreditation Standard with which the program has been found non-compliant within one calendar year.

1. If the written documentation is accepted the next comprehensive review shall be in three years.

2. If the written documentation is not accepted the accreditation is denied. This is an appealable action.

Denied

Initial accreditation of a transition-to-practice program is denied when the ACEN Board of Commissioners finds a program does not demonstrate compliance with two or more Accreditation Standards. This is an appealable action.

The transition-to-practice program may restart the Candidacy process at any time after the denial of initial accreditation.

CONTINUING ACCREDITATION

Granted

Continuing accreditation of a transition-to-practice program is granted when the ACEN Board of Commissioners finds a transition-to-practice program demonstrates compliance with all Accreditation Standards. Next review shall be in four years.

Granted With Contingency

Continuing accreditation with contingency of a transition-to-practice program is granted when the ACEN Board of Commissioners finds a transition-to-practice program demonstrates compliance with all but one or two Accreditation Standards. Next review shall be a review of written documentation regarding the Accreditation Standard(s) with which the program has been found non-compliant within one calendar year.

1. If the written documentation is accepted, the next comprehensive review shall be in three years.

2. If the written documentation is not accepted, the next review shall be a review of written documentation regarding the Accreditation Standard(s) with which the program has been found to be in continued non-compliance within one calendar year.

Upon review of the written documentation:

    • If the written documentation is accepted, the next comprehensive review shall be in two years.
    • If the written documentation is not accepted by the ACEN Board of Commissioners, accreditation is denied. This is an appealable action.

Denied

Continuing accreditation of a transition-to-practice program is denied when the ACEN Board of Commissioners finds a program does not demonstrate compliance with three or more Accreditation Standards. A transition-to-practice program denied continuing accreditation will be removed from the list of ACEN accredited transition-to-practice programs. Denial of continuing accreditation is an appealable action.

The transition-to-practice program may start the Candidacy process at any time after the denial of continuing accreditation and removal from the list of accredited transition-to-practice programs.

Policy 204 History

Initial Approval: July 24, 2019

A transition-to-practice program accredited by the ACEN or seeking ACEN initial accreditation explicitly agrees that if accreditation is granted, all records pertaining to that program may be made available to a regulatory agency, as appropriate.

Within 30 calendar days of the accreditation decisions made at the ACEN Board of Commissioners meetings, the ACEN staff will send written notification of the ACEN Board of Commissioners’ action to the nurse administrator, the chief nursing officer of the sponsoring organization (or chief executive officer if there is not a chief nursing officer), and the site visit team members.

Policy 205 History

Initial Approval: July 24, 2019

The nurse administrator may formally request a delay or rescheduling of a visit for continuing accreditation. The ACEN Chief Executive Officer makes the decision to grant or deny the request based on the reason(s) provided. The timeframe considered for a visit delay is up to six months. Delays are granted only when circumstances beyond the control of the transition-to-practice program occur; typically, these involve a major disruption (e.g., natural disaster, catastrophic fire) that interrupts the transition-to-practice program for current nurse residents. A change in the nurse administrator or implementation of a substantive change are not considered beyond the control of the transition-to-practice program.

Delays are not granted to transition-to-practice programs:

    • Already granted a delay.
    • With a current status of accreditation with contingency.
    • Having outstanding written documentation requested by the ACEN.*
    • Due for review following the granting of initial accreditation by the ACEN.

*If a transition-to-practice program does not submit the written documentation by the date requested, the transition-to-practice program will be presented for action to the ACEN Board of Commissioners at the next ACEN Board of Commissioners’ meeting.

A transition-to-practice program that is granted a delay will be returned to its original visit schedule for the next accreditation visit.

Policy 206 History

Initial Approval: July 24, 2019

Accredited transition-to-practice programs voluntarily withdrawing from ACEN accreditation must submit written notification of their decision signed by the chief nursing officer of the sponsoring organization (or chief executive officer if there is not a chief nursing officer) and the nurse administrator of the transition-to-practice program to the attention of the ACEN Chief Executive Officer. When a transition-to-practice program voluntarily withdraws from ACEN accreditation, the transition-to-practice program’s accreditation will continue through (1) the end of the transition-to-practice program’s current initial or continuing accreditation period or (2) a date specified by the transition-to-practice program prior to the end of the transition-to-practice program’s current initial or continuing accreditation period. The transition-to-practice program must specify the intended accreditation withdrawal date in its written notification to the ACEN. At the selected date of withdrawal, the transition-to-practice program will be removed from the ACEN’s list of accredited transition-to-practice programs. The transition-to-practice program must remove all references to ACEN accreditation intended to inform the public including all print and electronic documents.

The ACEN will deem as a voluntary withdrawal from accreditation any refusal or failure of an accredited transition-to-practice programs to allow a required site visit or focused visit, or submit a Self-Study Report, written documentation, or Focused Visit Report, or other requested information. The effective date of the withdrawal will be the last day of the month in which the requested information was due. The transition-to-practice program will be so notified, in writing, by the ACEN Chief Executive Officer within 30 calendar days of an accredited transition-to-practice program refusing or failing to submit to a required (1) site visit or focused visit (2) Self-Study Report, written documentation, or Focused Visit Report, (3) Annual Report, or (4) other requested information.

ACEN will deem as a voluntary withdrawal from accreditation any refusal or failure of an accredited transition-to-practice program to pay its fees and expenses when due. The effective date of the withdrawal will be the last day of the month in which the fees and/or expenses were due and not paid. The transition-to-practice program will be so notified, in writing, by the ACEN Chief Executive Officer within 30 calendar days of an accredited transition-to-practice program refusing or failing to pay its fees and expenses on a timely basis.

A transition-to-practice program may reinitiate the Candidacy process for initial accreditation at any time after voluntarily withdrawing from its initial accreditation process. A transition-to-practice program must voluntarily withdraw from the Candidacy process for initial accreditation before reinitiating the Candidacy process.

Policy 207 History

Initial Approval: July 24, 2019

When a sponsoring organization and/or transition-to-practice program makes a disclosure regarding the ACEN accreditation status of a transition-to-practice program, it must (1) accurately cite each transition-to-practice program option and (2) accurately identify each transition-to-practice program’s accreditation status with ACEN. “Fully accredited” must not be used, as partial accreditation is not possible.

The disclosure must include the name, address, telephone number, and web address of the ACEN as illustrated below.

Accreditation Commission for Education in Nursing (ACEN)
3343 Peachtree Road NE, Suite 850
Atlanta, GA 30326
404-975-5000
http://acenursing-ttp.org/

If the sponsoring organization and/or transition-to-practice program publishes incorrect or misleading information about the accreditation status of a transition-to-practice program or any action by the ACEN relative to the accreditation status of a transition-to-practice program, the sponsoring organization and/or transition-to-practice program must immediately provide public correction via a news release or through other media.

If a sponsoring organization and/or transition-to-practice program makes public the contents from a Site Visit Report, written documentation, Focused Site Visit Report, or Commission decision letter, it must provide full sentences and context. Characterizing, quoting, and/or providing excerpts from a Site Visit Report, written documentation, Focused Site Visit Report, or Commission decision letter must also be accompanied by a note stating that a copy of the complete document(s) can be obtained from the transition-to-practice program. Should the statements be misinterpreted, the transition-to-practice program must correct this misinterpretation through a clarifying release to the same audience that received the information. When it is determined that a sponsoring organization and/or transition-to-practice program is in violation of this policy, the ACEN Chief Executive Officer will inform the sponsoring organization and/or transition-to-practice program through a formal letter. If the violation is not corrected, the ACEN Chief Executive Officer shall report the matter to the ACEN Board of Commissioners for appropriate action.

Policy 208 History

Initial Approval: July 24, 2019

The appeal process allows a transition-to-practice program to appeal an adverse action taken by the ACEN Board of Commissioners.

DECISIONS ELIGIBLE FOR APPEAL

A transition-to-practice program may only appeal an adverse action taken by the ACEN Board of Commissioners. An adverse action is defined as a denial of initial accreditation or a denial of continuing accreditation.

GROUNDS FOR APPEAL

1. There are two grounds for appeal:

    • The ACEN Board of Commissioners’ decision was arbitrary; that is, it was unreasonable and not based on, or consistent with, the published Transition-to Practice Standards and Criteria or the ACEN published policies and/or procedures; or
    • The ACEN Board of Commissioners failed to follow its published transition-to practice policies and/or procedures and this failure was significant in leading to the Board of Commissioners’ decision.

NOTICE OF APPEAL

An adverse action taken regarding the accreditation status of a transition-to-practice program may be appealed within 30 calendar days of the transition-to-practice program’s receipt of notice of such adverse action. A transition-to-practice program shall initiate an appeal by filing a written notice of intent to appeal via hand delivery, certified/registered mail, or another means that provides written evidence of the delivery. The notice of appeal shall be sent by the chief nursing officer of the appellant transition-to-practice program’s sponsoring organization (or chief executive officer if there is not a chief nursing officer) to the ACEN Chief Executive Officer. Upon receipt of the notice, the ACEN shall maintain the prior accreditation status of the transition-to-practice program until the disposition of the appeal.

The request of a transition-to-practice program for an appeal process must identify the specific alleged procedural failures or the specific manner in which the decision was arbitrary, that is, was unreasonable and not based on, or consistent with, the published Transition-to Practice Standards and Criteria or ACEN published transition-to practice policies and/or procedures.

The appeal process will be completed within a reasonable amount of time following the date of receipt of the notice of intent to appeal. The date for the Appeal Hearing will be determined by the availability of Appeal Panel members to hear the case and by the establishment of a quorum. The final determination of the date will be made by the ACEN Chief Executive Officer after consultation with the Appeal Panel members and the appellant transition-to-practice program. The ACEN will make every effort to honor the preference of the appellant transition-to-practice program but cannot guarantee the date.

The notice of intent to appeal fee must be submitted with the written notice of intent to appeal. The appeal process fee is due within 45 calendar days of the submission of the notice of intent to appeal. The appeal will be considered withdrawn if the transition-to-practice program fails to submit the appeal process fee within 45 calendar days of the submission of the notice of intent to appeal. The Appeal Hearing will not be scheduled until the appeal process fee has been paid in full. Additionally, the appellant transition-to-practice program will be charged a non-refundable administrative appeal fee, which must be submitted with the written notice of intent to appeal. Credit cards are not an acceptable form of payment for the notice of intent to appeal fee, the appeal process fee, or the non-refundable administrative appeal fee.

If the travel, lodging, meal, legal, and other expenses directly related to the appeal process incurred by the ACEN exceed the cumulative total of the notice of intent to appeal fee and appeal process fee, the transition-to-practice program will be responsible for the difference and will receive a subsequent invoice for the additional expenses not covered by the fees. Credit cards are not an acceptable form of payment for invoices for appeal-related expenses. If the travel, lodging, meal, legal, and other expenses directly related to the appeal process incurred by the ACEN are less than the cumulative total of the notice of intent to appeal fee and appeal process fee, the transition-to-practice program will be refunded the difference. The appellant transition-to-practice program is responsible for all the travel, lodging, meal, legal, and other expenses directly related to the appeal process incurred by the ACEN regardless of the outcome, disposition, and/or cancellation of the Appeal Hearing.

APPOINTMENT OF AN APPEAL COMMITTEE

Three members from the Appeal Panel membership shall be appointed to an Appeal Committee to examine a specific appeal. One transition-to-practice program educator or one college/university nurse educator, one public member, and one nurse clinician/practitioner. Current members of the ACEN Board of Commissioners may not serve on the Appeal Panel.

The ACEN Chief Executive Officer shall appoint the Appeal Committee. A member of the Appeal Panel shall recuse him/herself from the Appeal Committee if there is a conflict of interest or an appearance of a conflict of interest. Appeal Panel and Appeal Committee members are subject to the requirements of ACEN Policy 201.

The ACEN Chief Executive Officer shall provide notice of the Appeal Committee membership to the appellant transition-to-practice program. The appellant transition-to-practice program will have the opportunity to review the proposed Appeal Committee members for any conflicts of interest. Within three business days of appellant transition-to-practice program’s receipt of the names of the proposed Appeal Committee membership, the appellant transition-to-practice program shall provide written notice of any assertions that a proposed Appeal Committee member has a conflict of interest to the ACEN Chief Executive Officer. If the ACEN Chief Executive Officer determines a conflict of interest exists, another Appeal Committee member shall be appointed within three business days with notification to appellant transition-to-practice program. The appellant transition-to-practice program shall have an opportunity to review the appointed Appeal Committee member for any conflict of interest. Within three business days of appellant transition-to-practice program’s receipt of the name of the appointed panel member, the appellant transition-to-practice program shall provide written notice of any assertion that the substituted Appeal Committee member has a conflict of interest to the ACEN Chief Executive Officer. If the ACEN Chief Executive Officer determines that the panel member has a conflict of interest, the procedures of this paragraph shall be repeated until an Appeal Committee member is secured and the Appeal Panel is determined. The ACEN Chief Executive Officer’s determination of a conflict of interest shall be final.

Where necessary to avoid a conflict of interest or in other exceptional circumstances, the ACEN Chief Executive Officer may, in consultation with the appellant transition-to-practice program, select individuals outside of the approved list maintained by the ACEN of persons qualified to serve as Appeal Panel members as long as such panel member otherwise meets the qualifications to be a panel member.

PROCEDURES FOR GOVERNING THE APPEAL PROCESS AND APPEAL HEARING

The Appeal Process and Appeal Hearing are collegial, and shall not be bound by technical or formal rules of evidence or pleading. The Appeal Hearing is an administrative process, not judicial hearing, with each party to the appeal advocating its position. Therefore, legal Rules of Evidence and legal procedures, such as the examination of the competency of members of the Appeal Committee, the use of sidebars, or cross-examining those present, are prohibited.

Throughout the Appeal Process and Appeal Hearing, the appellant transition-to-practice program will bear the burden of proof.

The ACEN is responsible for sending all material concerning the appeal to members of the Appeal Committee; for providing support services, including lodging, transportation and meeting space for the Appeal Committee members; for confirming the date of the Appeal Hearing; and for securing the services of a court reporter.

The following procedures must be adhered to in an appeal.

DOCUMENTS FOR THE HEARING

1. At least 30 calendar days before the date of the Appeal Hearing, the ACEN must submit to the appellant transition-to-practice program and the Appeal Committee documents (administrative record) used by the ACEN Board of Commissioners leading to and arriving at the decision regarding the transition-to-practice program. The administrative record includes the following: (a) minutes of the ACEN Board of Commissioners as pertain exclusively to the appellant transition-to-practice program’s case, (b) a historical summary of the actions taken by the ACEN involving the appellant transition-to-practice program, (c) the official ACEN correspondence leading to the adverse action and also related to the appeal, and (d) other documents bearing on the substance of the appeal.

2. At least 14 calendar days before the date of the Appeal Hearing, the appellant transition-to-practice program must submit to the ACEN Chief Executive Officer the brief it intends to present at the Appeal Hearing. The brief must specifically direct Appeal Committee members to citations in the administrative record which justify the appellant transition-to-practice program’s grounds for appeal. The appellant transition-to-practice program must cite page numbers of the text supporting its position. The appellant transition-to-practice program is required to submit five copies of its brief. Failure of the appellant transition-to-practice program to provide a brief within the specified period time shall be cause for case dismissal by the Appeal Committee.

3. At least 10 calendar days before the date of the Appeal Hearing, the ACEN is required to submit copies of the administrative record and the appellant transition-to-practice program’s brief to the Appeal Committee.

4. At least seven calendar days before the date of the Appeal Hearing, the ACEN must submit to the appellant transition-to-practice program and Appeal Committee its response to the appellant transition-to-practice program’s brief.

5. Neither the appellant transition-to-practice program nor the ACEN may submit additional briefs or any other materials during or following the Appeal Hearing.

THE HEARING

1. The Appeal Committee will select a Chair who will be responsible for ensuring effective implementation of the appeal process and for filing the Appeal Committee’s decision with the ACEN Chief Executive Officer.

2. The Chair of the Appeal Committee may have a preliminary conference, in person or by telephone, either at the Chair’s request or at the request of a party, to discuss the procedures for the appeal. The conference will be conducted by the Chair with representatives from both parties in attendance.

3. At least 14 calendar days before the date of the Appeal Hearing, the appellant transition-to-practice program and the ACEN must submit to each other the names and titles of those individuals selected to appear as witnesses, representatives, and legal counsel, one of whom must be the Nurse Administrator. Once the names are submitted to each other there may be no substitutions, except as may be approved by the Chair.

4. The ACEN Board of Commissioners bases its adverse action on reports, sponsoring organization responses, documentation, and evidence presented by the sponsoring organization at the time of its review. If the appellant transition-to-practice program failed to present documentation and evidence available at the time the ACEN Board of Commissioners took adverse action, it cannot make that information available for consideration by the Appeal Committee under any circumstances. In addition, neither the ACEN nor the appellant transition-to-practice program may include new information/materials as part of their briefs presented to the Appeal Committee nor may they introduce new evidence during the Appeal Hearing.

5. It is incumbent upon all parties to ensure that all evidence to be presented at the Appeal Hearing is submitted as required by ACEN Policy 210 Appeal Process for Review of Adverse Action.

6. The Appeal Hearing is closed to the public and shall include only those persons who can speak to the grounds for appeal.

7. Both parties are present during the Appeal Hearing.

8. No more than five persons and one attorney shall appear for each of the parties. The nurse administrator of the appellant transition-to-practice program shall appear before the Appeal Committee.

9. Attendees will be seated with counsel and may testify from where they sit. There will be no sequestration of witnesses.

10. The Appeal Committee may ask questions of the attendees, and their questions shall not count against the time allowed either side.

11. Legal counsel may not cross-examine witnesses for the other party and may not voice objections.

12. The presentation of the parties, including any questions of the Appeal Committee, shall be transcribed by a court reporter provided by the ACEN.

13. Since the appellant transition-to-practice program bears the burden of proof, the appellant transition-to-practice program will be the first party to present its case during the Appeal Hearing.

14. The Chair of the Appeal Committee will limit the presentation of the appellant transition-to-practice program and the ACEN to one hour each, and shall notify both before the Appeal Hearing of such time limit. The one hour does not include a time period for questioning from the members of the Appeal Committee. At the request of the appellant transition-to-practice program or the ACEN, the Chair may allow time for final response by either party, not to exceed one half-hour. These time limits can be extended only by the Chair. Since the sponsoring organization bears the burden of proof, the sponsoring organization will be the first party to present a final response and may reserve some time to conclude.

15. Within seven calendar days of the date of the Appeal Hearing, the Chair of the Appeal Committee shall inform the ACEN Chief Executive Officer and Chair of the ACEN Board of Commissioners in writing of the Appeal Committee’s decision. This notification must include specific reasons for the decision, must address each of the grounds for appeal identified by the appellant transition-to-practice program, and must address the findings with regard to the Transition-to Practice Standards and Criteria on which the ACEN Board of Commissioners’ decision was based. A PDF version of the letter of notification will be emailed and will be deemed acceptable by transmission. The original letter will be next-day express mailed to the chief nursing officer of the appellant transition-to-practice program’s sponsoring organization (or chief executive officer if there is not a chief nursing officer) and to the ACEN Chief Executive Officer.

CONDITIONS

1. The appellant transition-to-practice program bears the burden of proof.

    • To gain a REVERSAL of the ACEN Board of Commissioners’ decision, the appellant transition-to-practice program must present evidence which, in the judgment of the Appeal Committee, demonstrates that the ACEN Board of Commissioners’ decision was arbitrary, that is, was unreasonable and not based on, or consistent with, the published Transition-to-Practice Standards and Criteria or ACEN published transition-to-practice policies and/or procedures.
    • In order to gain a REMAND, the appellant transition-to-practice program must present evidence which, in the judgment of the Appeal Committee, demonstrates that the ACEN Board of Commissioners failed to follow its published transition-to-practice policies and/or procedures and that this failure was significant in leading to its decision.
    • If the appellant transition-to-practice program fails to provide evidence adequate to gain a REVERSAL or a REMAND, the initial decision of the ACEN Board of Commissioners must be AFFIRMED.

2. The accreditation status of an appellant transition-to-practice program for which an appealable action has been taken shall remain as it was before such action until the 10 calendar day period for filing an appeal has expired. Receipt of a notification of an appeal from an appellant transition-to-practice program by the ACEN Chief Executive Officer during this 10 calendar day period will cause the previous status to be continued until a final decision is made on the appeal. If the result of an appeal is to affirm the ACEN Board of Commissioners’ decision, the original effective end date of the transition-to-practice program’s accreditation is also affirmed.

RIGHTS AND LIMITATIONS

1. The appellant transition-to-practice program and the ACEN have the following rights in an appeal:

    • To have available legal counsel or a representative of their choice to advise them at the Appeal Hearing. Legal counsel representing each of the parties will be permitted to present or assist in the presentation of the case during the Appeal Hearing. Legal counsel will not be permitted to conduct a cross-examination of representatives from the opposing party.
    • If the Chair of the Appeal Committee, the appellant transition-to-practice program, or the ACEN requests a pre-hearing conference, the conference will be conducted by the Chair with representatives from both parties in attendance.
    • To present written or oral testimony and/or evidence pertinent to the grounds for the appeal consistent with this ACEN Policy 210 Appeal Process for Review of Adverse Action. Only the Appeal Committee has the right to question individuals present at the Appeal Hearing. All individuals who testify will testify under oath as administered by the court reporter.
    • To receive a transcript and any other related records of the Appeal Process and Appeal Hearing, upon payment of the costs of reproduction.
    • The Appeal Committee's discussions and deliberations, all votes taken, and the discussion on the final decision itself are not conducted on the record.
    • Presentations by the appellant transition-to-practice program and the ACEN, questions asked of these representatives by the Appeal Committee, and responses to such questions are to be recorded and transcribed. Transcripts are a matter of record of the proceedings.

2. The decision of the ACEN Board of Commissioners shall be reviewed based exclusively upon the conditions existing at the time of that decision and shall be subject to the following limitations:

    • No evidence concerning the remedying of deficiencies since the time of the ACEN Board of Commissioners’ adverse action shall be presented at or before the Appeal Hearing under any circumstances. The Appeal Committee is prohibited from considering such evidence in reaching its decision. No new evidence made available since the time of the ACEN Board of Commissioners’ adverse action shall be presented at or before the Appeal Hearing. The Appeal Committee is prohibited from considering such evidence in reaching its decision.
    • The Appeal Committee shall not, in its decision or otherwise, instruct the ACEN staff or the ACEN Board of Commissioners to consider evidence concerning the remedying of deficiencies since the date of the ACEN Board of Commissioners’ original decision.

3. The Chair of the Appeal Committee must disallow evidence presented by the appellant transition-to-practice program or the ACEN:

    • Which is not pertinent to the grounds for appeal;
    • Which concerns the remedying of deficiencies since the time of the ACEN Board of Commissioners’ decision;
    • Which was not available to the ACEN Board of Commissioners at the time of its decision.

4. Members of the Appeal Committee may not disclose the content of confidential discussions or deliberations leading to its decision.

5. Members of the Appeal Committee may not disclose its decision prior to the Chair’s notification to the ACEN Chief Executive Officer and the Chair of the ACEN Board of Commissioners.

ACTIONS

1. The Appeal Committee, after the presentation of oral and/or written testimony, must determine whether the appellant transition-to-practice program has demonstrated either of the following:

    • That the ACEN Board of Commissioners failed to follow its published transition-to-practice policies and/or procedures and that this failure was significant in leading to the Board of Commissioners’ decision; or
    • That the Board of Commissioners’ decision was arbitrary, that is, was unreasonable and not based on, or consistent with, the published Transition-to-Practice Standards and Criteria or ACEN published policies and/or procedures.

2. The Appeal Committee shall act within the following limitations:

    • AFFIRM the ACEN Board of Commissioners' decision
      • The Appeal Committee shall AFFIRM the ACEN Board of Commissioners’ decision, unless it finds that the appellant transition-to-practice program:
        • Demonstrated that the ACEN Board of Commissioners failed to follow its published transition-to-practice policies and/or procedures and that this failure was significant in leading to the ACEN Board of Commissioners’ decision; or
        • Demonstrated that the ACEN Board of Commissioners’ decision was arbitrary, that is, was unreasonable and not based on, or consistent with, the published Transition-to-Practice Standards and Criteria or ACEN published transition-to-practice policies and/or procedures.
      • The decision by the Appeal Committee to AFFIRM the ACEN Board of Commissioners' decision is final and is not subject to further appeal.
      • REVERSE the ACEN Board of Commissioners' decision
        • The Appeal Committee shall REVERSE the decision of the ACEN Board of Commissioners if it finds that the appellant transition-to-practice program has demonstrated that:
          • The ACEN Board of Commissioners’ decision was arbitrary, that is, was unreasonable and not based on, or consistent with, the published Transition-to-Practice Standards and Criteria or ACEN published transition-to-practice policies and/or procedures.
          • The decision by the Appeal Committee to REVERSE the ACEN Board of Commissioners' decision is final and is not subject to further appeal.

      • REMAND the ACEN Board of Commissioners' decision

      If the appellant transition-to-practice program demonstrated that the ACEN failed to follow its published transition-to-practice policies and/or procedures, the Appeal Committee shall remand to the specific group where the failure occurred.
        • The Appeal Committee shall REMAND the decision of the ACEN Board of Commissioners if it finds that the appellant transition-to-practice program has demonstrated that the ACEN failed to follow its published transition-to-practice policies and/or procedures, that the failure was significant in leading to the ACEN Board of Commissioners’ decision, and that the failure was significant in leading to the adverse action.
        • The Appeal Committee shall REMAND the case to the specific group where the failure occurred with specific instructions to review the case taking into consideration any findings of the Appeal Committee. The specific group where the failure occurred will reconsider the case and forward its recommendation to the next level of review.
        • If the Appeal Committee REMANDS the case, the reconsideration shall occur at the next realistic accreditation timeframe following the decision of the Appeal Committee.

      If the ACEN Board of Commissioners affirms its original decision, the appellant transition-to-practice program may again appeal based on the Grounds for Appeal. The case will be heard again by an Appeal Committee composed of different members, which will then make a final decision to affirm or reverse. The Appeal Committee cannot remand again.

      Policy 209 History

      Initial Approval: July 24, 2019

The ACEN provides notice of proposed new or revised policies. Interested parties are given an opportunity to comment prior to implementation.

Policy 210 History

Initial Approval: July 24, 2019

The ACEN maintains the following records for each transition-to-practice program:

1. Accreditation and Reaccreditation (from most recent review)

    • Self-Study Report
    • Site Visit Report
    • Nurse Administrator Response Form

2. Formal Written Correspondence (as applicable)

    • Commission Action on Accreditation Status
    • Commission Action on Substantive Change Prospectus and/or Letter of Notification
    • Complaints (see ACEN Policy 217)
    • Correspondence between the ACEN and the sponsoring organization and/or transition-to-practice program
3. Reports (as applicable)
    • Focused Visit Report
    • Focused Site Visit Report
    • Written documentation
    • Substantive Change Prospectus and/or Letter of Notification
    • Candidacy Application Form (for a period of three years or until initial accreditation is earned, whichever occurs first)
    • Candidacy Presentation (for a period of three years or until initial accreditation is earned, whichever occurs first)

Selected records for transition-to-practice programs that have voluntarily withdrawn from the accreditation process or been denied initial or continuing accreditation are maintained by the ACEN.

Policy 211 History

Initial Approval: July 24, 2019

TRANSITION-TO-PRACTICE PROGRAM OBLIGATIONS

It is the responsibility of each transition-to-practice program to notify the ACEN of major changes in a transition-to-practice program to ensure maintenance of accreditation status and protection of nurse residents in accordance with policy. Failure to report a substantive change places the accreditation status of a transition-to-practice program in jeopardy.

The ACEN reserves the right to reconsider the accreditation status of a transition-to-practice program at any time. The ACEN Board of Commissioners may also take action to require formal monitoring of a transition-to-practice program due to non-compliance with any Accreditation Standard.

Based on ACEN policy, a substantive change is a significant modification or expansion of the nature and scope of a transition-to-practice program. The different types of substantive change, the specific procedure to be used for each, the respective approval/notification requirement, and the reporting timeline are included in the following table:

PROCEDURE FOR REPORTING A SUBSTANTIVE CHANGE: AN OVERVIEW

The nurse administrator with responsibility for the transition-to-practice program should submit a letter of notification to the ACEN within the specified timeframe. The letter of notification should include details about the change for the ACEN to review and evaluate the program’s compliance with the Transition-to-Practice Standards and Criteria, including but not limited to the rationale or reason for the change and the date the change occurred or will occur. If the substantive change is related to a decline in program outcomes, the letter of notification should include any plans developed to address the areas of decline.

POLICY STATEMENTS REGARDING SUBSTANTIVE CHANGE

1. The Transition-to-Practice Standards and Criteria apply to all ACEN-accredited transition-to-practice programs wherever the transition-to-practice program is located or however the transition-to-practice program is delivered.

2. Failure to comply with the Transition-to-Practice Standards and Criteria or with the procedures referred to in this policy could result in the transition-to-practice program being removed from the list of accredited transition-to-practice programs.

3. The ACEN substantive change transition-to-practice policy applies only to accredited transition-to-practice programs. The substantive change transition-to-practice policy does not apply to programs in Candidacy. Transition to practice programs that have achieved Candidacy status should refer to Policy 225 for information about program changes that should be reported to the ACEN prior to achieving initial accreditation.

4. The ACEN reserves the right to classify significant changes other than those described above as substantive in nature and to follow up accordingly. The follow-up procedure may include a focused visit. See Policy 215.

5. A transition-to-practice program may withdraw/discontinue a substantive change at any time prior to the review by either the ACEN staff or the ACEN Board of Commissioners by submitting a formal letter of withdrawal to the ACEN Chief Executive Officer. 6. ACEN staff will conduct a review of all substantive changes upon receipt. Substantive change submissions may be referred to the ACEN Board of Commissioners if the ACEN staff determine the substantive change may affect the program’s compliance with the Transition-to-Practice Standards and Criteria.

7. The ACEN staff acceptance of a substantive change is effective as of the date on the acceptance letter sent to the governing organization/nursing program.

8. If indicated, the ACEN Board of Commissioners’ approval of a substantive change is effective as of the date of the Board’s approval; this date will be noted in the approval letter sent to the governing organization/nursing program.

9. Extensive substantive changes by a transition-to-practice program may accelerate the date for the transition-to-practice program’s next continuing accreditation. Examples of triggers for an accelerated continuing accreditation include but are not limited to frequent mergers or consolidations or rapid proliferation of new transition-to-practice program types.

TRANSITION-TO-PRACTICE PROGRAM RESPONSIBILITIES

It is the responsibility of a transition-to-practice program to follow the substantive change procedures and inform the ACEN of substantive changes as specified in this policy and procedures. If a nurse administrator is unclear as to whether a change is substantive in nature, he or she should contact the ACEN staff for consultation.

ACEN AND COMMISSION RESPONSIBILITIES

The ACEN accredits transition-to-practice programs wherever a transition-to-practice program is located or however a transition-to-practice program is delivered. The ACEN is responsible for reviewing all substantive changes that occur, determining whether the change has affected the quality of the transition-to-practice program, and assuring the public that all aspects of the transition-to-practice program continue to meet the Transition-to-Practice Standards and Criteria.

Policy 212 History

Initial Approval: July 24, 2019

When a sponsoring organization makes the decision to close a transition-to-practice program, current nurse residents should be notified of the decision as soon as possible. Nurse residents who have not completed the transition-to-practice program should be advised regarding available options, if any.

When a sponsoring organization makes the decision to close a transition-to-practice program a Closing Report that fully describes the plan for closing must be submitted to the ACEN. The Closing Report must describe how the transition-to-practice program will fulfill any outstanding obligations to the nurse residents enrolled in the program.

Based on the information provided in the Closing Report, the accreditation status of the transition-to-practice program, and the date of the next scheduled accreditation visit, the ACEN will take one of the following actions:

1. When the transition-to-practice program is accredited without stipulations, the ACEN Chief Executive Officer will:

    • Cancel the next visit and continue accreditation until closing; or
    • Reaffirm the originally scheduled visit.
2. When the current status of the transition-to-practice program is continuing accreditation with contingency, the ACEN Chief Executive Officer will:
    • Extend the contingency status if the transition-to-practice program is scheduled to close within 12 months after the scheduled visit; or
    • Determine the date of a next visit if the transition-to-practice program is scheduled to close beyond a year after the scheduled visit.

3. If a program planning to close fails to submit a Closing Report to the ACEN or comply with Commission request(s), such action will constitute a declaration to have accreditation status withdrawn, and the ACEN Chief Executive Officer will take action accordingly.

4. If a program previously scheduled to close extends its operation beyond the original closing date, a site visit will be scheduled at the earliest possible date. The procedure to be followed will depend on the transition-to-practice program’s status at the time the announcements about the closing and the change of plans were made.

5. If a program closes in the interim between Commission meetings and without prior notice to the ACEN, the closing automatically terminates ACEN accreditation.

Policy 213 History

Initial Approval: July 24, 2019

The sponsoring organization offering an ACEN-accredited transition-to-practice program must be accredited by an agency recognized by the ACEN. If the sponsoring organization’s accrediting agency revokes its accreditation of the sponsoring organization, the nurse administrator shall submit to the ACEN a report explaining the reasons for the decision and the effect of the decision on the transition-to-practice program. The ACEN Board of Commissioners will determine appropriate follow-up actions following review of the submitted materials.

Policy 214 History

Initial Approval: July 24, 2019

The ACEN Board of Commissioners may determine a focused visit is warranted in order to review significant accreditation-related information disclosed about a program as a result of:

1. A substantive change;

2. Information revealed about a transition-to-practice program between periods of scheduled review;

3. Information is received that the sponsoring organization’s accrediting body revoked its accreditation; or

4. Information is received that a state regulatory agency has changed the status of the transition-to-practice program.

The Standards and Criteria pertinent to the reason for the focused visit will be reviewed. ACEN professional staff will determine the Standards and Criteria to be reviewed. The transition-to-practice program must prepare a Focused Visit Report based on the Standards and Criteria identified and submit the Report to the peer evaluators and ACEN six weeks before the site visit; the Focused Visit Report is the foundation for review of compliance with the identified Standards and Criteria. Guidelines for creating the Focused Visit Report are available on the ACEN website. The focused visit is typically one to two day(s) in length.

Following the focused visit, the Focused Site Visit Report will be reviewed by the ACEN Board of Commissioners at a regularly scheduled meeting. Based on the Focused Site Visit Report, the ACEN Board of Commissioners may take the following actions:

1. Affirm the transition-to-practice program’s accreditation status and date of the next scheduled visit; no further information is requested.

2. Change the date of the transition-to-practice program’s next scheduled visit to a date earlier than previously scheduled. This is not an appealable action.

3. Change the transition-to-practice program’s accreditation status to continuing accreditation with contingency.

4. Deny continuing accreditation and remove the transition-to-practice program from the listings of accredited transition-to-practice programs. This is an appealable action. See ACEN Policy 210.

The maximum period for the status of continuing accreditation with contingency for transition-to-practice programs to be monitored is two years from the ACEN Board of Commissioners’ determination of this accreditation status.

Policy 215 History

Initial Approval: July 24, 2019

The ACEN will only act upon substantiated complaints against an accredited transition-to-practice program that indicate:

1. A sponsoring organization’s and/or transition-to-practice program’s non-compliance with the Standards and Criteria;

2. A sponsoring organization’s and/or transition-to-practice program’s non-compliance with an ACEN policy; and/or

3. A sponsoring organization’s and/or transition-to-practice program’s non-compliance with its own published policy as said policy relates to the Standards and Criteria.

The ACEN will not interpose itself as a reviewing authority in individual matters such as, but not limited to, program acceptance; application of sponsoring organization or program policies; financial matters; disciplinary matters; contractual rights and obligations; personnel decisions; or similar matters. The ACEN will also not seek any type of compensation, damages, or other redress on an individual’s behalf. The ACEN will not respond to or take action upon any complaint that is defamatory, hostile, or profane. In addition, the ACEN will not involve itself in collective bargaining disputes. The ACEN does not accept complaints about individuals.

In addition, the ACEN may act upon concerns from a recognized state or federal agency.

Records of program complaints will be maintained by the ACEN for four years. If a number of program complaints suggest a pattern of concern not evident from any single complaint, the ACEN may renew its consideration of a matter for whatever action may be appropriate.

The ACEN expects that the individual complainant will attempt to resolve an issue through the sponsoring organization and/or transition-to-practice program’s own published grievance policy/procedures before submitting a complaint to the ACEN. Therefore, an individual must use all available grievance and means of appeal within the sponsoring organization and/or transition-to-practice program before filing a complaint with the ACEN. The ACEN will not consider a complaint while sponsoring organization’s proceedings or litigation appertaining thereto are ongoing. However, if the ACEN determines that the complainant raises issues so immediate that a delay may jeopardize the transition-to-practice program’s accreditation status or cause harm to nurse residents, the ACEN may, at its discretion, choose to proceed with its review.

The ACEN will not review or act upon a complaint to which the sponsoring organization and/or transition-to-practice program’s published grievance policy/procedures apply if it is formally filed with the ACEN more than one calendar year after the completion of the policy/procedures. The ACEN will not review or act upon a complaint to which such policies/procedures do not apply if it is formally filed with the ACEN more than one calendar year after the circumstances leading to the complaint.

SUBMITTING A COMPLAINT

1. The complaint must be presented to the ACEN as a written, signed, and dated statement with supporting documentation. The ACEN will not review or act upon complaints that are not presented in writing.

2. All complaints must be submitted using the ACEN’s official Complaint Form, which must be completed in its entirety. The ACEN’s official Complaint Form is available at: HYPERLINK. Complaints submitted without the official Complaint Form, completed in its entirety, will not be reviewed or acted upon.

3. The completed Complaint Form and the required supporting documentation must be submitted to the ACEN via the United States Postal Service or an express carrier (e.g., UPS, FedEx, DHL).

4. The completed Complaint Form and the required supporting documentation may be submitted to the ACEN in paper format or using a portable electronic storage device (e.g., USB).

5. The ACEN will not review or act upon anonymous complaints, nor will it review or act upon complaints submitted by an individual or agency on behalf of another individual. For example, the ACEN will not review or act upon a complaint from a parent, spouse, child, sibling, co-worker, or friend of a complainant, or from an attorney.

6. The ACEN must be the original intended recipient of the complaint and will not review or act upon complaints that are forwarded to the ACEN.

7. The ACEN will not accept or discuss complaints via telephone.

8. All written materials, including the submitted Complaint Form, the required supporting documentation, and any other printed materials, must be presented in English.

Each sponsoring organization and transition-to-practice program is required to have in place written nurse resident complaint policies and procedures that are reasonable, fairly administered, and well publicized. The sponsoring organization and transition-to-practice program must maintain a record of complaints received. This record must be available to the ACEN upon request. The records for the transition-to-practice program will be examined by the ACEN as part of the transition-to-practice program’s initial or continuing accreditation review.

ACEN PROCEDURE FOR PROCESSING COMPLAINTS

1. The ACEN will acknowledge a complaint within 15 business days of its receipt.

2. Within 60 business days after acknowledging receipt of the complaint, the ACEN staff will review the complaint and determine whether:

    • it is related to the transition-to-practice program’s accreditation status,
    • it is within the scope of transition-to-practice policy, and/or
    • it demonstrates the sponsoring organization’s and/or transition-to-practice program’s non-compliance with:
      • the Standards and Criteria,
      • an ACEN policy, and/or
      • the sponsoring organization’s and/or transition-to-practice program’s own published policy as said policy relates to the Standards and Criteria, and
    • there is adequate evidence in support of the allegations made in the complaint.
  • 3. If the complaint does not have sufficient substance to warrant further review, the ACEN will communicate this to the complainant, in writing, within 15 business days of reaching this conclusion.

    4. If the complaint has sufficient substance to warrant further review, the ACEN will make every effort to expedite its review; however, the time required to conduct its review may vary considerably depending on the circumstances and nature of the complaint.

    5. When a complaint is reviewed further, a copy of the complaint will be forwarded to the nurse administrator of the transition-to-practice program, who will be asked to respond to the ACEN within 20 business days. Upon receipt of a response from the nurse administrator, the ACEN reserves the right to request additional materials, as needed, from the complainant and/or nurse administrator.

    6. If there is insufficient evidence of non-compliance, the complaint will not be processed further. The decision of the ACEN Chief Executive Officer is final, and the complainant and nurse administrator will be notified of this outcome.

    7. If there appears to be sufficient evidence of non-compliance or if the ACEN staff are unable to determine compliance, the following actions may be taken by the ACEN Chief Executive Officer (the complainant and nurse administrator will be notified of this outcome):

      • The complaint may be forwarded directly to the ACEN Board of Commissioners for review and action.
      • The ACEN Chief Executive Officer may authorize a Focused Visit to evaluate the sponsoring organization/transition-to-practice program. The Focused Visit Team will examine documents and interview sponsoring organization’s personnel to analyze and make a judgment regarding compliance, after which they will prepare a Focused Site Visit Report. This Report will be forwarded to the ACEN Board of Commissioners for review and action at the next meeting of the Board. Following that meeting, the complainant and nurse administrator will be notified of the Board’s decision.
      • The complaint allegations may be reviewed as part of an upcoming scheduled visit to the transition-to-practice program. The peer evaluators will examine documents and interview sponsoring organization’s personnel to analyze and make a judgment regarding compliance, after which they will prepare a Site Visit Report. This Report will be forwarded to the ACEN Board of Commissioners for review and action at the next meeting of the Board. Following that meeting, the complainant and nurse administrator will be notified of the decision of the Board.
    • For items 7a, 7b, or 7c above, the decision of the ACEN Board of Commissioners is final unless appealable as delineated in ACEN Policy 210 Appeal Process and Submission and Review of New Financial Information Subsequent to Adverse Action.

      Policy 216 History

      Initial Approval: July 24, 2019

The Transition-to-Practice Standards and Criteria are developed, reviewed, and revised periodically by means of procedures that involve continuous input from accredited transition-to-practice programs and identified communities of interest. The ACEN ensures the circulation of proposed revisions to the Transition-to-Practice Standards and Criteria and the opportunity for comment from interested parties.

Policy 217 History

Initial Approval: July 24, 2019

The ACEN maintains an ongoing systematic review designed to ensure that (1) the Transition-to-Practice Standards and Criteria are valid and reliable indicators of the quality provided by accredited transition-to-practice programs and are relevant to the needs of nurse residents; (2) ACEN processes are reliable and assess knowledge and consistency of observations, applications, decisions, and perceptions; and (3) there are broad communications and consultations across constituencies.

The findings from the ongoing review are used for development, maintenance, and revision of the Transition-to-Practice Standards and Criteria, processes, and practices. Evidence to support ongoing systematic review appears in Commission minutes, annual reports, the ACEN Report to Constituents, on the ACEN website, and at the ACEN Forums.

THE PROCESS OF REVIEW

The process of review:

    • Is comprehensive,
    • Occurs at regular intervals,
    • Examines each Standard and its accompanying Criteria as a whole,
    • Involves relevant constituencies in the review,
    • Affords relevant constituencies a meaningful opportunity to provide input into the review, and
    • Requires that needed changes be made promptly to improve the ACEN’s effectiveness and efficiency and the consumer friendliness of ACEN products and services.

ASPECTS OF THE REVIEW

A full review of the Transition-to-Practice Standards and Criteria occurs every five years. The process consists of:

    • Review of ongoing data analysis,
    • Review of literature for trends in evaluation, nursing practice, and nurse residency programs,
    • Distribution of draft versions to constituencies for comment,
    • Review of comments and revision of drafts,
    • Distribution of the revised drafts for comment,
    • Review of comments and revision of drafts as needed, and
    • Commission adoption of revised Transition-to-Practice Standards and Criteria for transition-to-practice programs.

RELIABILITY OF ACEN PROCESSES

Reliability is ensured by:

    • Analysis of internal consistency and reliability of the accreditation status recommendations/decisions across the three levels of review trended over time,
    • Identification of strengths and areas needing development by Criterion across the three levels of review trended over time, and
    • Analysis of the perceived effectiveness of the planning and conduct of the accreditation site visit by the transition-to-practice program and the site visit teams trended over time.

COMMUNICATION AND BROAD CONSULTATION PRACTICES

Communication is ensured by:

    • Solicitation of comments on proposed new or revised policies from interested parties,
    • Distribution of the Annual Report findings in the Report to Constituents and on the ACEN website as aggregated data trended over time, and
    • Broad consultation across constituencies.

PLANNED USE OF DATA ANALYSIS

Data analysis is used to:

    • Maintain validity and relevance of the Transition-to-Practice Standards and Criteria for transition-to-practice programs,
    • Maintain reliability of the ACEN accreditation processes and practices,
    • Continue to identify and disseminate information in appropriate arenas regarding specific education needs of programs and peer evaluators as groups,
    • Continue to identify and disseminate information in appropriate arenas regarding specific developmental needs of individual programs and peer evaluators, and
    • Continue to identify and disseminate information in appropriate arenas regarding areas in which change needs to be facilitated.

EVALUATION OF THE SITE VISIT

For each site visit, the transition-to-practice program, nurse administrator, team chair, and team members have an evaluation form to complete. The information is used to:

    • Improve the quality of the accreditation process, and
    • Identify potential team chairs.

ANNUAL REPORT

All accredited transition-to-practice programs are required to submit an Annual Report.

The Annual Report will request, at a minimum, the following information:

    • Program participation data, and
    • Program outcomes data.

The ACEN staff will review the information to ensure that programs continue to comply with policies and reporting requirements. Significant changes will be referred to the ACEN Board of Commissioners and action may be taken as appropriate. Failure to submit the Annual Report could result in the ACEN Board of Commissioners taking appropriate action, including potentially altering the transition-to-practice program’s accreditation status.

Data will be compiled by the individual programs for monitoring purposes and reported in aggregate form, trended over time.

Policy 218 History

Initial Approval: July 24, 2019

ACEN professional staff members are expected to advise and inform the ACEN Board of Commissioners on matters relative to a transition-to-practice program. They should offer advice or provide information at their own initiative or at the request of the ACEN Board of Commissioners. Such advice and information do not supplant the peer review process, but rather provide additional insight in reaching an informed judgment.

PROCEDURAL GUIDELINES

1. In order to maintain the strength and consistency of the process, professional staff members provide information and advice as appropriate when assisting the ACEN Board of Commissioners in making a decision on the accreditation status of a program. Particularly germane is historical information on similarly situated transition-to-practice programs and procedural and substantive advice on how the transition-to-practice policies and Transition-to-Practice Standards and Criteria have been interpreted and could be applied to a program's case, including possible action and follow-up. This information may be presented orally during the Board of Commissioner’s discussion.

2. The professional staff role in the deliberations is an active role. Professional staff members provide information and advice, which may include evidence and evidence-based professional opinions on a transition-to-practice program’s patterns, progress, and suggested action.

3. The professional staff’s role in the process will not supplant the peer review and decision process.

Policy 219 History

Initial Approval: July 24, 2019

It is the obligation of every accredited transition-to-practice program to pay all fees and expenses when due. Failure to pay fees and expenses when due shall be deemed a voluntary withdrawal from accreditation pursuant to ACEN Policy 207 Voluntary Withdrawal from ACEN Accreditation.

A billing statement for annual accreditation fees shall be issued annually to every accredited transition-to-practice program, and fees are payable upon receipt.

A billing statement of fees and expenses incurred by ACEN in carrying out its accreditation functions shall be issued, and fees are payable upon receipt.

A schedule of current fees and expenses is available at: http://acenursing-ttp.org/for-programs/fees-domestic/

Policy 220 History

Initial Approval: July 24, 2019

COSTS OF COMPLIANCE WITH THIRD-PARTY DISCOVERY REQUESTS

The costs of compliance with third-party discovery requests made on ACEN with regard to accredited transition-to-practice programs can be high and cannot be reasonably anticipated for budgeting purposes. To defray these costs in part, where reimbursement for the expense of producing the documents is not provided by the party serving the subpoena or document request, ACEN may charge the transition-to-practice programs with the costs of production, including the costs of copying and delivering the documents and attorney’s fees incurred in compliance with the subpoena or request.

SPONSORING ORGANIZATIONSAL FINANCIAL OBLIGATIONS FOLLOWING LITIGATION

Any transition-to-practice program that takes legal action against ACEN regarding an accreditation decision and withdraws its case or loses its case is responsible for assuming all costs incurred by ACEN while defending its decision, including attorney’s fees. These costs must be paid in full within 45 calendar days following the transition-to-practice program’s receipt of the invoice, unless other arrangements are approved by the Executive Committee acting on behalf of the ACEN Board of Commissioners.

CHOICE OF LAW, JURISDICTION, AND VENUE

As a condition of ACEN accreditation, each transition-to-practice program acknowledges that all agreements created by the ACEN granting any status shall be deemed to have been entered into in Fulton County, Georgia, and shall be interpreted in accordance with the laws of the State of Georgia. Further, each transition-to-practice program agrees that jurisdiction and venue for any action which might arise from any accreditation agreement between the transition-to-practice program and ACEN, regardless of which party shall initiate the action, shall be exclusively in the United States District Court for the Northern District of Georgia or the state courts of Fulton County, Georgia, whichever of these courts shall have proper subject matter jurisdiction.

Policy 221 History

Initial Approval: July 24, 2019

ADVERTISING, PUBLICATIONS, PROMOTIONAL LITERATURE

The sponsoring organization/transition-to-practice program ensures in the sponsoring organization’s publications that:

1. The transition-to-practice program and sponsoring organization services offered to facilitate nurse resident success are the primary emphasis of all advertisements, publications, promotional literature, and recruitment activities.

2. All statements and representations are clear, factually accurate, and current. Supporting information is kept on file and readily available for review.

3. The publications are freely accessible (e.g., website, print copy) and accurately depict the current:

    • sponsoring organization and transition-to-practice program purpose and goals
    • participation requirements and procedures for all nurse residents
    • nurse resident obligations to the sponsoring organization
    • end-of-program learning outcomes and program outcomes
    • nurse resident conduct rules
    • nurse resident grievance policy and procedures
    • nurse resident achievement data that is consistent with Standard 5 – Outcomes

All nurse resident achievement data reported/published for any purpose is expected to reflect an accurate and verifiable portrayal of nurse residents’ performance in a transition-to-practice program, which is subject to review for integrity, accuracy, and completeness. The ACEN reserves the right to request that a sponsoring organization/transition-to-practice program provide verification by an external source of a transition-to-practice program nurse residents’ achievement data that the ACEN relies on, in part, in making an accreditation decision. The sponsoring organization/transition-to-practice program is responsible for any cost related to verification by an external source of a transition-to-practice program’s nurse resident achievement data.

NURSE RESIDENT RECRUITMENT

1. Nurse resident recruitment is conducted by well-qualified recruitment staff, staff of the sponsoring organization, or and trained volunteers whose credentials, purpose, and position or affiliation with the sponsoring organization are clearly specified.

2. Independent contractors or agents used by the sponsoring organization for recruiting purposes are governed by the same principles as sponsoring organization employees.

3. Sponsoring organizations do not engage in the following practices:

    • offering or assuring benefits for completion of the transition-to-practice program that cannot be verified,
    • misrepresenting nurse resident obligations to the transition-to-practice program or sponsoring organization, or
    • making disparaging comparisons of other healthcare services agencies or agencies offering a transition-to-practice program.

Policy 222 History

Initial Approval: July 24, 2019

As sponsoring organizations/transition-to-practice programs seek ways to provide a quality program for nurse residents, the sponsoring organization/transition-to-practice program may find that it is practical or efficient to engage an external source to directly deliver to nurse residents a component or components of the ACEN-accredited transition-to-practice program. The components of the ACEN-accredited transition-to-practice program that can be directly delivered from an external source to nurse residents include traditional instructional delivery methods, hybrid instructional delivery methods, and distance education instructional delivery methods.

Education-related components from external sources can include, but are not limited to:

1. Engaging another provider/organization to directly educate nurse residents enrolled in its ACEN-accredited transition-to-practice program.

2. Participating in a consortium to directly educate nurse residents using selected components of the sponsoring organization’s ACEN-accredited transition-to-practice program curriculum.

A sponsoring organization/transition-to-practice program accredited by the ACEN is responsible for all activities carried out under its name. All Transition-to-Practice Standards and Criteria, policies, and procedures apply to any agreement with an external source for any transition-to-practice-related component(s). The sponsoring organization/transition-to-practice program should be especially mindful of ACEN Policy 213 Reporting Substantive Changes and Policy 216 Complaints Against an Accredited Transition-to-Practice Program.

The following are required for a sponsoring organization and its ACEN-accredited transition-to-practice program entering into an agreement with an external source to provide an education-related components or components, whether the external source holds or does not hold sponsoring organization and/or programmatic accreditation:

1. The primary purpose of the component(s) is to support nurse residents’ success.

2. The sponsoring organization/transition-to-practice program is responsible for the accuracy of all advertising, recruiting, and promotional materials.

3. The sponsoring organization/transition-to-practice program is responsible for informing the external source that the agreement does not imply or extend ACEN accreditation to the external source.

4. Every component must be consistent with the sponsoring organization’s/transition-to-practice program’s mission and objectives as they were at the time of the last evaluation conducted by the ACEN.

5. Every component must be consistent with the published end-of-program learning outcomes and program outcomes for the transition-to-practice program.

6. While the sponsoring organization’s personnel may or may not teach the component(s), the transition-to-practice program educators and appropriate sponsoring organization representatives must retain overall accountability for and control of the integrity, rigor, and currency of the nurse residency related component(s).

7. The sponsoring organization/transition-to-practice program must ensure ongoing collaboration between the transition-to-practice program educators, appropriate sponsoring organization representatives, and the external source to safeguard the integrity, rigor, and currency of the transition-to-practice program. Evidence of collaboration, including periodic and adequate review of work performed by the external source, must be available.

8. The sponsoring organization/transition-to-practice program is ultimately responsible for all aspects of its ACEN-accredited transition-to-practice program, including but not limited to:

    • Nurse residents’ successful achievement of end-of-program learning outcomes and program outcomes;
    • Admissions to the transition-to-practice program;
    • Review and approval of all nurse residency related component(s);
    • Review and approval of the appointment/selection of all program educators, whether or not the transition-to-practice program educator is employed by the sponsoring organization of the ACEN-accredited transition-to-practice program;
    • Quality of resources and services available to nurse residents;
    • Nurse resident and program educator access to resources and services that support the transition-to-practice program; and
    • Ensuring the privacy of nurse residents and the security of their records.

There must be a written agreement between the sponsoring organization/transition-to-practice program and external source that is executed by duly designated officer(s) of the sponsoring organization/transition-to-practice program and appropriate counterparts from the external source.

The agreement clearly establishes and defines:

1. The scope and nature of the work to be performed by each party;

2. A mechanism to account for the scope and nature of the work provided by each party;

3. The period of the agreement and the conditions under which any possible renewal, renegotiation, or termination could take place;

4. Appropriate protection for participating nurse residents in the event that the agreement is terminated or renegotiated;

5. Appropriate avenue(s) for addressing perceived breaches of the agreement;

6. How appropriate representatives from both parties will periodically review the success of the agreement;

7. The compensation and other considerations for the transition-to-practice program-related component provided by both parties;

8. How necessary nurse resident and program educator support services and resources will be assured;

9. How nurse resident and program educator access to support services and resources will be assured;

10. The procedure for a nurse resident grievance regarding any aspect of the transition-to-practice program-related component; and

11. How outcomes assessment will be conducted on the transition-to-practice program-related component(s), if appropriate;

The agreement is:

1. Submitted to federal and/or state agencies for approval, when required;

2. Submitted to the ACEN for approval, when required, as specified in ACEN Policy 213 Reporting Substantive Changes; and

3. Available on request to the ACEN and peer evaluators acting on its behalf.

Policy 223 History

Initial Approval: July 24, 2019

A sponsoring organization and/or transition-to-practice program shall demonstrate honesty and integrity in all disclosures to the ACEN and its representatives, nurse residents, and the public. A sponsoring organization/transition-to-practice program in disclosing any information to the ACEN and its representatives, nurse residents, and the public shall:

1. Disclose all voluntary, required, or requested information in a timely manner;

2. Fully, accurately, and straightforwardly disclose all voluntary, required, or requested information, including data, whether complimentary or otherwise; and

3. Comply with all the ACEN’s requirements, policies, guidelines, decisions, and requests.

The ACEN accredits transition-to-practice programs, not individuals. Therefore, any individual who reports to the ACEN on behalf of a sponsoring organization/transition-to-practice program, either by virtue of his or her office (e.g., nurse administrator) or as delegated by the chief nursing officer of the sponsoring organization (or chief executive officer if there is not a chief nursing officer), obligates the sponsoring organization and transition-to-practice program in all matters regarding integrity. Additionally, in order to comply with the requirements for honesty and integrity, appropriate representatives (e.g., nurse administrator, chief nursing officer, etc.) of the sponsoring organization are obligated to review and ensure the honesty and integrity of information disclosed.

With due regard for confidentiality, a sponsoring organization/transition-to-practice program applying for Candidacy or seeking initial or continuing accreditation shall provide the ACEN and its representatives with unrestricted access to all aspects of its operations, including information about the sponsoring organization’s/transition-to-practice program’s affairs, including, but not limited to, reports of other accrediting, licensing, and auditing agencies.

If the ACEN has reason to believe that a sponsoring organization/transition-to-practice program has breached this policy, the ACEN will conduct an investigation and issue a report of its findings. The investigation will use an appropriate process. The sponsoring organization/transition-to-practice program will have the opportunity to respond to any alleged breach prior to the ACEN imposing a sanction.

Presenting false, distorted, or incomplete information of any type, either through intent or through failure to exercise care and diligence, is considered a breach of this policy. Failure to respond appropriately to the ACEN decisions and requests in a timely manner, or to make complete, accurate, and honest disclosure, is sufficient reason, in and of itself, for the ACEN to impose a sanction.

Verified breaches may adversely affect the sponsoring organization’s/transition-to-practice program’s accreditation status with the ACEN. Depending on the seriousness of the breach, sanctions by the ACEN Board of Commissioners may result in a letter of censure, being placed on contingent status, being denied continuing accreditation and being removed from the list of accredited transition-to-practice programs, or being denied initial accreditation. Only the decisions by the ACEN Board of Commissioners to deny initial accreditation or to deny continuing accreditation and remove a sponsoring organization/transition-to-practice program from the list of accredited transition-to-practice programs are appealable actions.

Policy 224 History

Initial Approval: July 24, 2019

A sponsoring organization/transition-to-practice program seeking initial accreditation with the ACEN must apply for Candidacy. The sponsoring organization/transition-to-practice program seeking initial accreditation must:

1. Demonstrate that the sponsoring organization and transition-to-practice program are eligible for ACEN accreditation; See ACEN Policy 203 Eligibility for Accreditation.

2. After the eligibility of the sponsoring organization and transition-to-practice program have been established by ACEN staff, pay the required Candidacy fee(s).

3. Demonstrate that the transition-to-practice program has the potential to achieve initial accreditation based on requirements for the Candidacy Presentation and within the timeframe established by the ACEN.

Approval, Deferral, or Disapproval of Candidacy

Based on the requirements established by the ACEN, the Chief Executive Officer may (a) approve a transition-to-practice program for Candidacy, (b) defer a transition-to-practice program for Candidacy, or (c) disapprove a transition-to-practice program for Candidacy.

A program may be approved for Candidacy to pursue initial accreditation for a maximum of two years. Once approved for Candidacy, a transition-to-practice program must host an initial accreditation site visit prior to the expiration of Candidacy.

Approval of Candidacy

Approval of Candidacy is granted when, in the professional judgment of the ACEN Chief Executive Officer, informed by the professional judgement of the ACEN staff, the transition-to-practice program either:

    • Makes a Candidacy Presentation that demonstrates the transition-to-practice program is currently compliant with the requirements for the Candidacy Presentation and based upon the Candidacy Presentation, has the potential to achieve initial accreditation; or
    • Makes a Candidacy Presentation that demonstrates the transition-to-practice program has the potential to be compliant with the requirements for the Candidacy Presentation within two calendar years of the date of notification, and based upon the Candidacy Presentation, has the potential to achieve initial accreditation.

Being approved for Candidacy informs the sponsoring organization/transition-to-practice program and the public that the transition-to-practice program demonstrated the potential to achieve initial accreditation based upon the ACEN staff’s professional judgement regarding requirements for the Candidacy Presentation at the time the transition-to-practice program was approved for Candidacy. Being approved for Candidacy does not guarantee that the ACEN Board of Commissioners will determine that the transition-to-practice program is in compliance with all the Transition-to-Practice Standards and Criteria at the time the ACEN Board of Commissioners reviews the transition-to-practice program for initial accreditation. See ACEN Policy 204 Types of Commission Actions for Initial and Continuing Accreditation

Transition-to-practice programs approved for Candidacy must publicly disclose the following information exactly as illustrated below.

Effective [insert date of ACEN notification letter], this transition-to-practice program is a candidate for initial accreditation by the Accreditation Commission for Education in Nursing. This candidacy status expires on [insert expiration date in ACEN notification letter].

Accreditation Commission for Education in Nursing (ACEN)
3343 Peachtree Road NE, Suite 850
Atlanta, GA 30326 404-975-5000
http://acenursing-ttp.org/

Note: Upon granting of initial accreditation by the ACEN Board of Commissioners, the effective date of initial accreditation is the date the transition-to-practice program was approved as a Candidate program by the ACEN that resulted in the ACEN Board of Commissioners granting initial accreditation.

Deferral of Candidacy

Deferral of Candidacy is granted when, in the professional judgment of the ACEN Chief Executive Officer, informed by the professional judgement of the ACEN staff, the transition-to-practice program:

    • Makes an inconsistent Candidacy Presentation that does not demonstrate that the transition-to-practice program is currently compliant with the requirements of the Candidacy Presentation. Deferral indicates the transition-to-practice program may have the potential to demonstrate compliance with the Candidacy Presentation with the opportunity to resubmit the Candidacy Presentation.

Being deferred for Candidacy informs the sponsoring organization/transition-to-practice program that the transition-to-practice program demonstrated that it may have the potential to achieve Candidacy based upon the ACEN staff’s professional judgement regarding requirements for the Candidacy Presentation at the time the transition-to-practice program was deferred for Candidacy. Being deferred for Candidacy does not guarantee that the transition-to-practice program will be approved for Candidacy if the transition-to-practice program resubmits the Candidacy Presentation.

Deferral of Candidacy is not an appealable action.

If deferred, the transition-to-practice program has up to one calendar year of the date of notification to resubmit the Candidacy Presentation for reconsideration without restarting the entire Candidacy Process and paying related fee(s) again. Upon resubmission of the Candidacy Presentation, the transition-to-practice program must be (a) approved for Candidacy or (b) disapproved for Candidacy.

Disapproval of Candidacy

Disapproval of Candidacy is made when, in the professional judgment of the ACEN Chief Executive Officer, informed by the professional judgement of the ACEN staff, the transition-to-practice program either:

    • Does not make a Candidacy Presentation that demonstrates that the transition-to-practice program is currently compliant with the requirements for the Candidacy Presentation and based upon the Candidacy Presentation, does not have the potential to achieve initial accreditation; or
    • Does not make a Candidacy Presentation that demonstrates that the transition-to-practice program has the potential to be compliant with the requirements for the Candidacy Presentation within two calendar years of the date of notification, and based upon the Candidacy Presentation, does not have the potential to achieve initial accreditation.

Disapproval of Candidacy is not an appealable action.

If disapproved, in order to seek initial accreditation with ACEN, the transition-to-practice program is required to restart the Candidacy Process and pay related fee(s) again. The transition-to-practice program may restart the entire Candidacy process at any time after being disapproved for Candidacy.

Failure to Meet any Timeline

During the Candidacy process, failure to meet any timeline established by the ACEN will result in a transition-to-practice program losing its approval for Candidacy status. If a transition-to-practice program fails to meet any required timeline prior to hosting an initial accreditation site visit, then the transition-to-practice program must restart the entire Candidacy process, pay related fee(s), and submit a new Candidacy presentation, which may result in approval, deferral, or disapproval. Submission of a new Candidacy Eligibility Application and Candidacy Presentation reinitiates the Candidacy process for the transition-to-practice program, and the effective date of initial accreditation will be based on the new date that the transition-to-practice program is approved to pursue initial accreditation.

The Candidacy process can be restarted at any time after a transition-to-practice program loses its approval for Candidacy status or voluntarily withdraws from the Candidacy process.

Obligations of Sponsoring Organization and Transition-to-Practice Program Approved for Candidacy

Each sponsoring organization/transition-to-practice program making a Candidacy Presentation or approved for Candidacy agrees to certain requirements concerning financial obligation, choice of law, jurisdiction, and venue. As a condition of reviewing any Candidacy Presentation or of being approved for Candidacy, each sponsoring organization/transition-to-practice program agrees to the following:

    • The sponsoring organization/transition-to-practice program agrees to abide by ACEN Policy 221 Litigation.
    • It is the obligation of every sponsoring organization/transition-to-practice program seeking Candidacy to pay all fees and expenses when due. Failure to pay all fees and expenses when due shall be deemed a voluntary withdrawal from the Candidacy process. A schedule of current fees and expenses is available at http://acenursing-ttp.org/for-programs/fees-domestic/.

The sponsoring organization/transition-to-practice program must notify the ACEN, in writing, of (a) all unexpected changes that occur within 30 calendar days of the change or (b) all expected changes that are planned to occur no less than 120 calendar days prior to the change occurring. Failure to report an unexpected or expected change may delay or jeopardize a transition-to-practice program from being approved for Candidacy; hosting an initial accreditation site visit; or being granted initial accreditation by the ACEN Board of Commissioners.

Changes requiring notification include but are not limited to:

    • change in the nurse administrator
    • the transition-to-practice program relocates to a new location
    • change in the sponsoring organization’s and/or transition-to-practice program’s status with a state regulatory agency or for international programs a change in the approval status with any regulatory agency that oversees nursing in the country
    • change in the status with the sponsoring organization’s accrediting agency
    • change in the sponsoring organization’s accrediting agency
    • change in the transition-to-practice program’s curriculum
    • addition and/or deletion of a new location where the transition-to-practice program is offered

The written notification must address the requirements for the Candidacy Presentation related to the change (e.g., for a change in the curriculum and/or new program option, all of the required Criteria in the Candidacy Presentation for Standard 4 Curriculum).

If the ACEN Board of Commissioners grants initial accreditation but determines there is an unreported change, the ACEN Board of Commissioners may decide to exclude the unreported change in its initial accreditation decision of the transition-to-practice program. If the ACEN Board of Commissioners excludes the unreported change in its initial accreditation decision, then the transition-to-practice program is required to submit the unreported change through the ACEN substantive change policy, undergo the subsequent review process, and is obligated for any related expense(s) that results from the substantive change process. See ACEN Policy 213 Reporting Substantive Changes.

Policy 225 History

Initial Approval: July 24, 2019

1. If the ACEN is notified that the accreditation status of the sponsoring organization of an ACEN-accredited transition-to-practice program was changed by its institutional accrediting agency, the ACEN will promptly review the program to determine what action should be taken. See ACEN Policy #215.

2. If the ACEN is notified that the approval status of the sponsoring organization of an ACEN-accredited transition-to-practice program was changed by a state agency, the ACEN will promptly review the program to determine what action should be taken. See ACEN Policy #215.

3. If the ACEN is notified that the status an ACEN-accredited transition-to-practice program was changed by a state agency, the ACEN will promptly review the program to determine what action should be taken. See ACEN Policy #215.

Policy 226 History

Initial Approval: July 24, 2019

PURPOSE

The Accreditation Commission for Education in Nursing (ACEN) supports the use of its trademarks and service marks, and the ACEN name when used in an appropriate manner. The ACEN adopted this policy to communicate the appropriate and permissible manner in which its trademarks may be used. Doing so maintains the reputation of the ACEN and protects its trademarks and service marks, and the ACEN name.

ACEN TRADEMARKS AND SERVICE MARKS

The ACEN requires that all of its trademarks and service marks, and the ACEN name are always used properly. The ACEN maintains a portfolio of trademarks and service marks, which take various forms and include but are not limited to: trade dress, type style, letters, words, logos, designs, images, slogans, colors, product shapes, product packaging, sound, and the look, design, and overall commercial impression. The ACEN trademarks and service marks that may be used by an entity are accessible through the following hyperlink: https://www.acenursing.org/guidelines-accreditation-seal/. This list may be updated as other trademarks and service marks are created or registered. All other ACEN trademarks and service marks not available at the aforementioned https://www.acenursing.org/guidelines-accreditation-seal/ may not be used by any entity other than the ACEN.

The ACEN acknowledges that the use of a trademark or service mark, or the ACEN name may be necessary and encourages the appropriate use of an ACEN trademark or service mark, or the ACEN name. All use must be accurate and descriptive in nature and comply with this policy. Any use of an ACEN trademark or service mark, or the ACEN name must comply with the following:

1. A reference to any ACEN trademark or service mark, or the ACEN name must be clearly identified, truthful, accurate, not misleading, and used for which the ACEN trademark or service mark, or the ACEN name was originally intended by the ACEN.

2. The use of any ACEN trademark or service mark, or the ACEN name must maintain the integrity of the ACEN trademark or service mark, or the ACEN name.

    • Any trademark or service mark, or the ACEN name must be used as an adjective with a noun that properly and accurately identifies the ACEN product, service, program, material, or technology to which a user is referencing. Never reference any trademark or service mark as a noun.
    • Always use the proper spelling for any ACEN trademark or service mark, or the ACEN name.
    • Always use any ACEN trademark or service mark, or the ACEN name in the singular form; do not use in the plural or possessive form.

3. The use of any ACEN trademark or service mark, or the ACEN name must be applied correctly.

    • Always use the registered trademark and service mark symbol "®" when referring to an ACEN registered trademark and service mark (e.g., ______®).
    • Always use the unregistered trademark and service mark symbol "TM" when referring to an ACEN unregistered trademark and service mark.
    • Use the proper symbol ("®" or "TM") with each ACEN trademark and service mark, and apply the proper symbol consistently in every copy of communication, document, packaging, or other material in which an ACEN trademark, a service mark, or the ACEN name appears, regardless of the medium.

4. While another entity’s mark can be used in context with an ACEN trademark, a service mark, or the ACEN name to indicate a relationship between the ACEN and the other entity, the ACEN trademark, service mark, or the ACEN name must remain distinct. A reference to an ACEN trademark, a service mark, or the ACEN name must be clearly, visually distinguishable and separate from any product, service, program, material, or technology as well as any other logos, trademarks, or service trademarks.

Certain activities may constitute infringement or dilution of an ACEN trademark, a service mark, or the ACEN name and are not permitted. Prohibited and unauthorized use an ACEN trademark, a service mark, or the ACEN name include but are not limited to the following:

1. Do not use an ACEN trademark, a service mark, or the ACEN name in a manner that is likely to dilute, defame, disparage, or harm the reputation of the ACEN.

2. Do not use an ACEN trademark, a service mark, or the ACEN name in a manner that is likely to cause confusion about the ACEN, the ACEN mission, purpose, or goals, or ACEN accreditation.

3. Do not use an ACEN trademark, a service mark, or the ACEN, or any designation that is confusingly similar to the ACEN, the ACEN name, or an ACEN trademark, a service mark, or the ACEN name.

4. Do not use an ACEN trademark, a service mark, or the ACEN name in any way not intended by the ACEN.

5. Do not use an ACEN trademark, a service mark, or the ACEN name in a manner that is likely to give the impression or otherwise imply an affiliation or association between another entity or the entity’s product, service, program, material, or technology.

6. Do not alter, adapt, modify, animate, or morph an ACEN trademark, a service mark, or the ACEN name. Examples include but are not limited to: abbreviating or shortening any ACEN trademark or service mark; combining or hyphenating any ACEN trademark or service mark with another prefix or word; or using a slash mark with any ACEN trademark or service mark.

7. Do not copy or imitate an ACEN trade dress, type style, letters, words, logos, designs, images, slogans, colors, product shapes, product packaging, sound, or product packaging or the look, design, or overall commercial impression of an ACEN website, blog, or other materials.

8. Do not register or use any domain name that incorporates an ACEN trademark, a service mark, or the ACEN name.

9. Do not register or seek to register an ACEN trademark, a service mark, or the ACEN name or any restricted or trademark or service mark, or name that is confusingly similar to an ACEN trademark, a service mark, or the ACEN name.

HOW TO REPORT ANY MISUSE OR ABUSE OF THIS POLICY

Please report any misuse or abuse of this policy at http://acenursing-ttp.org/about/contact-us/ and provide as much information as possible about the use that might be an infringement. The ACEN will investigate the use and take appropriate action, if warranted.

Policy 227 History

Initial Approval: July 24, 2019

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